Payment Information

Personal Information

FIRST NAME:*

LAST NAME:*

ADDRESS:*

CITY:*

STATE:*

ZIP:*

OCCUPATION:

EMPLOYER:

T-Shirt Size & Color*

Billing Address

Same as Personal Address

ADDRESS:*

CITY:*

STATE:*

ZIP:*

Confirm and Submit

• I affirm that I am making this contribution via my personal credit or debit card for which I have a legal obligation to pay, and not through a corporate or business entity card or the card of another person.• My contribution is made from personal funds, and not from the general treasury funds of a corporation, organization or national bank.• I have not received any funds from another person or entity for the purposes of making this contribution.• I am a United States citizen, or a Green Card Holder who has been lawfully admitted for permanent residence and this contribution will not be reimbursed by another person.